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Lateral Lumbar Interbody Fusion

In many areas, nonessential orthopaedic procedures that were postponed due to COVID-19 have resumed. For information:  Questions and Answers for Patients Regarding Elective Surgery and COVID-19. For patients whose procedures have not yet been rescheduled:  What to Do If Your Orthopaedic Surgery Is Postponed.

Spinal fusion is a surgical procedure used to correct problems with the small bones in the spine (vertebrae). It is essentially a welding process. The basic iea is to fuse together the painful vertebrae so they heal into a single, solid bone. Spinal fusion is a treatment option when motion is the source of pain —  the theory being that if the painful vertebrae do not move, they should not hurt.

This article focuses on one method of fusing the lumbar (lower spine — lateral lumbar interbody fusion — and discusses just the surgical component of the procedure. For a complete overview of spinal fusion, including approaches, bone grafting, complications, and rehabilitation, please go to Spinal Fusion.

Interbody Fusion

An interbody fusion is a type of spinal fusion that involves removing the intervertebral disk from the disk space.

When the disk space has been cleared out, your surgeon will implant a metal, plastic, or bone spacer between the two adjoining vertebrae. This spacer, or cage, promotes bone healing and facilitates the fusion. After the cage is placed in the disk space, the surgeon may add stability to your spine by using metal screws, plates, and rods to hold the cage in place.

Lateral Lumbar Interbody Fusion

An interbody fusion can be performed using a variety of different approaches. For example, a surgeon can access the spine through incisions in the lower back or through incisions in the front of the body.

In a lateral lumbar interbody fusion, the surgeon takes a side approach and centers the incision over the patient's flank. With this approach, the surgeon can reach the vertebrae and intervertebral disks without moving the nerves or opening up muscles in the back.

The lateral approach is often referred to as extreme lateral or direct lateral interbody fusion (XLIF or DLIF). The surgeon accesses the spine by going through the psoas muscle, the muscle that enables the hip to flex, rotate, and adduct (move toward the midline of the body).

patient positioning for lateral lumbar interbody fusion

A patient in a side-lying position for lateral lumbar interbody fusion.

Surgical Technique

During the surgery, the patient is placed in the side position and the operating table is bent to provide the surgeon with a maximum view of the spine.

In some cases, the surgeon inserts an instrument called a tubular retractor through the skin and soft tissues down to the spinal column. The tubular retractor holds the muscles open and gives the surgeon a clear view of the spine.

During the procedure, the surgeon removes the disk and inserts a cage packed with bone graft between the vertebrae. Often, titanium screws are used to hold the cage in place, inserted through an additional incision on the back.

x-ray of cage and screws for interbody fusion

This X-ray taken from the side shows the cage between the vertebrae and screws that are stabilizing the spine.

Advantages and Disadvantaes of Lateral Lumbar Interbody Fusion

Each surgical approach — whether from the front, back, or side — has advantages and disadvantages. The potential advantages of a lateral lumbar fusion include:

  • Less damage to the midline back muscles
  • Easier access to the spine, in many cases
  • Improved alignment of the spinal bones

In addition, a lateral fusion may be performed with a less invasive technique, resulting in reduced muscle injury.

These results can also be achieved through fusions performed from the back or the front.

Typically, the complication rate for the lateral procedure is lower than for traditional spinal surgery. Possible disadvantages include:

  • Anterior thigh pain, which is usually temporary
  • Nerve damage, which can result in weakness in lifting up the leg
  • Rare incidence of bowel, bladder, or blood vessel injury (<0.1%)
  • Incisional hernia (where the muscle seems to pouch out)

Talk to your surgeon about the approach that will best meet your health needs.

Recovery

Patients typically go home the same day or next day if only one level is fused. If more than one level is fused, most patients stay overnight.

After going home, patients should watch for any belly pain or weakness in the legs that make their legs buckle, and alert the surgeon right away if these symptoms occur.

Pain medication is usually needed for a few days to weeks. Your surgeon may also provide you with a brace ot help the fusion heal.

Outcomes for lateral lumbar interbody fusion are equivalent to those of traditional surgeries. Because this procedure is performed through a smaller incision, it may minimize muscle damage.

Future Directions

Newer technology has led to the development of cages composed of different materials, which can be used to improve the fusion rate. In addition, expandable cage technology is being used to insert smaller devices which can then expand to fit your anatomy. By using a smaller cage, there may be less chance of muscle and nerve damage.

Finally, surgeons are commonly using a different variation of the lateral procedure called the oblique or anterior to the psoas technique, in which the surgeon does not go through the psoas muscle to approach the spine. This technique can theoretically decrease the risk of nerve damage and muscle pain, but there is a slightly higher risk of blood vessel and bladder injury. Complications from any lateral procedure, including the oblique anterior to the psoas approach are still very rare. 

Last Reviewed

September 2021

Contributed and/or Updated by

Daniel K. Park, MD, FAAOSLouis G. Jenis, MD

Peer-Reviewed by

Thomas Ward Throckmorton, MD, FAAOSStuart J. Fischer, MD

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website.